Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-00037-154 | Review of Mental Health Clinical Pharmacists in Veterans Health Administration Facilities | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures facility medical staff bylaws are consistent with Veterans Health Administration policy regarding clinical pharmacist practice as non-independent practitioners.
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2 The Under Secretary for Health ensures collaborating agreements, also referenced as collaborative practice agreements, are in place for mental health clinical pharmacists who provide outpatient collaborative medication management.
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3 The Under Secretary for Health ensures that the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews existing Veterans Health Administration guidance and provides assistance in outlining the mental health clinical pharmacist’s responsibilities for communication with the collaborating licensed independent practitioner who has prescribing authority.
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4 The Under Secretary for Health affirms allowable clinical duties within mental health clinical pharmacists’ scopes of practice include comprehensive provisions related to mental health.
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5 The Under Secretary for Health ensures a process is in place for chiefs of mental health service to document review, recommendation, and endorsement of all outpatient mental health clinical pharmacists’ scopes of practice, regardless of whether the clinical pharmacist is aligned with the mental health service line, and monitor compliance.
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6 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews and provides input into the patient referral process to mental health clinical pharmacists with consideration for ensuring that accurate diagnoses can be reliably identified by and conveyed to the mental health clinical pharmacists.
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7 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews the patient referral process to mental health clinical pharmacists and provides input with consideration for clinical settings or scenarios in which a review of the clinical complexity of the referral by a licensed independent practitioner with prescribing authority would be appropriate, prior to treatment.
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8 The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director establishes guidance and provides assistance in outlining when and how mental health clinical pharmacists are to refer patients to a higher level of mental health care.
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9 The Under Secretary for Health initiates a risk assessment of outpatient mental health clinical pharmacists’ practice and establish mitigation plans; and includes the Veterans Health Administration Office of Mental Health and Suicide Prevention Director in the design, implementation, and analysis processes.
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| 19-00022-153 | Delay in Diagnosis and Subsequent Suicide at a Veterans Integrated Service Network 15 Medical Facility | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures that the planning and implementation of the new electronic medical record includes, (a) a fail-safe system that allows communication and tracking of test results to multiple clinical staff members who coordinate patient notification, appropriate follow-up testing and clinical management, and (b) the ability to monitor actions taken by the responsible provider(s).
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2 The Veterans Integrated Service Network 15 Medical Facility Director initiates an administrative review of the clinical care the patient received and takes action as appropriate based on the results.
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3 The Veterans Integrated Service Network 15 Medical Facility Director ensures that Patient Centered Management Module provider and patient assignments are timely, and data are validated as required by Veterans Health Administration policy.
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4 The Veterans Integrated Service Network 15 Medical Facility Director issues guidance that establishes a clearly-defined process for the designation of surrogates to include abnormal test results and consults.
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5 The Veterans Integrated Service Network 15 Medical Facility Director confirms that once issued, providers are trained on the process for designation of surrogates and monitor compliance.
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6 The Veterans Integrated Service Network 15 Medical Facility Director reviews current view alert parameters, evaluates providers’ knowledge and management of view alerts, and takes action, as necessary, to ensure and monitor compliance.
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7 The Veterans Integrated Service Network 15 Medical Facility Director evaluates communication among Patient Aligned Care Team members, including the sharing of, the timeliness of, and the response to patient secure messages, and takes action based on the evaluation.
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8 The Veterans Integrated Service Network 15 Medical Facility Director reviews processes within Primary Care related to patient notification of test results and takes action to ensure test results are communicated to patients as required by Veterans Health Administration policy.
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9 The Veterans Integrated Service Network 15 Medical Facility Director reviews Veterans Health Administration and the Veterans Integrated Service Network 15 Medical Facility policies concerning disclosure of adverse events to patients and/or their representatives and ensures that staff are aware of discussions and documentation required to comply with these policies.
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10 The Veterans Integrated Service Network 15 Medical Facility Director reviews the events in the patient’s care and conducts additional actions related to the disclosure of adverse events to the patient’s representative as warranted by Veterans Health Administration and Veterans Integrated Service Network 15 Medical Facility.
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11 The Veterans Integrated Service Network 15 Medical Facility Director reviews quality management practices and ensures compliance with Veterans Health Administration guidance related to root cause analysis when future adverse events are identified and takes action as necessary.
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| 19-00266-141 | Staffing and Vacancy Reporting under the MISSION Act of 2018 | Review | ||
1 Ensure VA vacancy data are reported by occupation as required by Section 505(a)(1)(c) of the Mission Act.
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2 Make certain that VA staffing gains and losses data are reported by quarter as required by Section 505(a) part (b) of the MISSION Act.
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3 Annotate limitations clearly within the staffing and vacancy data to improve transparency and usability of the data, to include changes from HR Smart data cleansing efforts.
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4 Ensure that the staffing and vacancy reporting Web-site maintains historical information on the data elements required by the MISSION Act.
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5 Update the methodology for collecting and reporting on VA staffing and vacancy data to ensure consistency in future quarters.
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| 18-02765-144 | Alleged Deficiencies in Out of Operating Room Airway Management Processes at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The VA Eastern Kansas Health Care System Director implements documentation training for facility staff, including the Associate Chief of Staff for Education, and monitors compliance with out of operating room airway management documentation for completeness and accuracy.
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2 The VA Eastern Kansas Health Care System Director verifies that facility out of operating room airway management policy and out of operating room airway management providers comply with Veterans Health Administration requirements.
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3 The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management staff are trained as required and monitor compliance, including tracking verification of out of operating room airway management competencies.
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4 The VA Eastern Kansas Health Care System Director ensures that facility policy and use of Veterans Administration Form 10-0544, Privilege and Competency Verification, is consistent with VHA requirements.
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5 The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management workgroups monitor progress toward implementation of Veterans Health Administration Directive 1157(1), Out of Operating Room Airway Management, June 14, 2018, Amended September 19, 2018.
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6 18-02765-144The VA Eastern Kansas Health Care System Director verifies that facility leaders review the VetPro process and ensures all credentialing and privileging files are complete as required by VHA policy and takes action as necessary based on the findings.
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7 The VA Eastern Kansas Health Care System Director verifies that the Cardiopulmonary Resuscitative Committee analyzes and aggregates data and implements desired changes, as outlined Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation, and monitors compliance.
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| 18-03260-102 | Alleged Unapproved Acquisition of a Robotic Surgical System for the W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina | Audit | ||
1 The Deputy Under Secretary for Health for Operations and Management directs the Healthcare Technology Management Program Office to clarify High Cost, High Tech approval requirements to Veterans Integrated Service Network 6 officials, including biomedical engineers, logistics staff, equipment specialists, and financial officers, and to the Veterans Health Administration Procurement and Logistics Office.
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2 The Veterans Integrated Service Network 6 network director updates and disseminates VHA requirements to request Assistant Deputy Under Secretary for Health for Administrative Operations approvals for High Cost, High Tech purchases that cost over $1 million, including surgical robots, to the members of the Veterans Integrated Service Network 6 Capital Investment Board and Veterans Integrated Service Network 6 staff.
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3 The Veterans Integrated Service Network 6 Capital Investment Board meets each fiscal year to ensure that all facility equipment requests more than $1 million are reviewed in a timely manner, including fiscal year-end purchases.
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| 18-04673-138 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures utilization management reviewers complete at least 75 percent of all inpatient stay reviews and monitors the reviewers’ compliance.
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2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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3 The facility director ensures the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the Cardiopulmonary Resuscitation Committee’s compliance.
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4 The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated timeframes and monitors clinical managers’ compliance.
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5 The facility director makes certain that controlled substances program staff perform one random day’s reconciliation of controlled substances returned to pharmacy from every automated dispensing unit during monthly inspections and monitors the program staff’s compliance.
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6 The facility director ensures that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
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7 The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training requirements no later than 90 days after entering their position and monitors providers’ compliance.
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8 The chief of staff ensures clinicians provide and document patient/caregiver education and monitors clinicians’ compliance.
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9 The chief of staff makes certain that program managers implement a process for trackingcervical cancer screening data and monitors program managers’ compliance.
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10 The chief of staff confirms that providers notify patients of abnormal cervical pathology results within the required timeframe and monitors providers’ compliance.
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11 The facility director ensures that the urgent care center is discontinued and patient needs and flow are more adequately addressed in the established emergency department and primary care clinic, and monitors compliance.
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| 18-04676-142 | Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital, Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief Business Office revenue-utilization review and monitors the committee’s compliance.
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2 The facility director ensures the Acute and Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
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3 The chief of staff makes certain that the Medicine Service Line chief includes required gastroenterology-specific criteria in ongoing professional practice evaluations of gastroenterology practitioners and monitors the Medicine Service Line chief’s compliance.
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4 The associate director confirms storage rooms meet fire safety requirements by maintaining the required amount of open space between fire sprinkler deflectors and the top of stored items and monitors compliance.
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5 The associate director ensures that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
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6 The facility director makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
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7 The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
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8 The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
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9 The facility director confirms that the Women Veterans Health Committee includes required core members, designated members consistently attend meetings, and monitors the committee’s compliance.
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10 The chief of staff ensures that program managers implement a process for tracking results notification and follow-up care data for abnormal cervical cancer screenings and monitors program managers’ compliance.
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| 18-02405-146 | Review of Environment of Care, Infection Control Practices, Provider Availability, and Leadership, VA Loma Linda Healthcare System, California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Health Care System Director ensures implementation of system-wide comprehensive environment of care practices and a safe, sanitary, and high-quality environment consistent with Veterans Health Administration policy.
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2 The VA Loma Linda Health Care System Director makes certain that Environmental Management Service managers establish standard operating procedures and consistent processes for staff training.
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3 The VA Loma Linda Health Care System Director implements a standardized process and accountability for validating Environmental Management Service staff competencies.
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4 The VA Loma Linda Health Care System Director verifies compliance with Veterans Health Administration policies for Sterile Processing Services controls.
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5 The VA Loma Linda Health Care System Director complies with Veterans Health Administration policies developed to support Infection Prevention and Control Program issues identified in this report.
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6 The VA Loma Linda Health Care System Director ensures that hot water temperature systems are 124 degrees Fahrenheit or higher to inhibit Legionella growth.
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7 The VA Loma Linda Healthcare System Chief of Staff and Associate Director of Patient Care Services implements a standardized process, consistent with Veterans Health Administration policy, to notify clinical staff involved in direct patient care when routine environmental water testing is positive for Legionella to increase diagnostic awareness.
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8 The VA Loma Linda Health Care System Director continues to recruit and hire for hospitalist vacancies.
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9 The VA Loma Linda Health Care System Director monitors action plans for the Mental Health Strategic Analytics for Improvement and Learning measures.
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10 The VA Loma Linda Health Care System Director completes a review of mental health staffing and continues efforts to recruit and hire for Mental Health Service vacancies.
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11 The Veterans Integrated Service Network 22 Director verifies that the Loma Linda VA Health Care System Director implements action items from previous external Veterans Health Administration site reviews.
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12 The VA Loma Linda Health Care System Director makes certain that senior leaders consistently attend comprehensive environment of care monitoring rounds.
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13 The VA Loma Linda Health Care System Director designates staff members to consistently enter data into the Comprehensive Environment of Care Assessment and Compliance Tool and takes action, as necessary, to complete or address environment of care deficiencies to meet Environmental Program Service goals.
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14 The Veterans Integrated Service Network 22 Director establishes a Veterans Integrated Service Network comprehensive environment of care policy and the VA Loma Linda Health Care System Director implements a facility level policy as required.
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| 17-04178-46 | VA’s Administration of the Transformation Twenty-One Total Technology Next Generation Contract | Audit | ||
1 The Technology Acquisition Center associate executive director provide written requirements, in designation memoranda or other written medium, that identify the method and level of detail required for program office contracting officers’ representatives to adequately document their review of contractor deliverables and determination of acceptability.
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2 The Technology Acquisition Center associate executive director develop procedures for Technology Acquisition Center contracting officers to ensure review and acceptability of contractor deliverables is adequately documented in contract files to help prevent improper payments.
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3 The Technology Acquisition Center associate executive director develop timeliness requirements for program office contracting officers’ representatives to submit contractor performance assessments.
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4 The Technology Acquisition Center associate executive director develop written follow-up procedures that standardize the actions Technology Acquisition Center contracting officers should take when program office contracting officers’ representatives do not comply with the developed timeliness requirements.
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5 The Technology Acquisition Center associate executive director implement procedures to monitor Technology Acquisition Center contracting officers’ actions through compliance reviews to ensure they adhere to written procedures.
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6 The Technology Acquisition Center associate executive director assess the risk introduced by removing the requirement to review Past Performance Information Retrieval System records and implements a control that mitigates this risk.
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7 The Technology Acquisition Center associate executive director enhance written procedures by providing Technology Acquisition Center contracting officers with standards that define higher-risk financial stability risk scores and subsequent actions that should be taken when these scores are identified.
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| 17-03399-140 | Alleged Complications Associated with Phototherapy at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Gulf Coast Veterans Health Care System Director confirms current dermatology clinic nursing practice requirements related to ensuring informed consent prior to initiating phototherapy are followed and monitors compliance.
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2 The Gulf Coast Veterans Health Care System Director ensures dermatology clinic registered nurse training and competencies are completed as required and tracked for compliance.
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3 The Gulf Coast Veterans Health Care System Director reviews facility policy to ensure guidance clearly delineates environmental actions to be taken following identification of bed bugs.
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4 The Gulf Coast Veterans Health Care System Director ensures that all Gulf Coast Veterans Health Care System staff are trained on the policy addressing environmental actions to be taken following identification of bed bugs and track compliance.
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5 The Gulf Coast Veterans Health Care System Director ensures that the Patient Safety Manager completes all actions identified in the subject adverse event review.
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6 The Veterans Integrated Service Network 16 Director reviews the Gulf Coast Veterans Health Care System policy related to the confidentiality of fact-finding reviews to evaluate if the initiation of such reviews, including the one conducted in relation to this patient, is consistent with the purpose of maintaining the confidentiality of quality management activities, and takes action as necessary.
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7 The Veterans Integrated Service Network 16 Director reviews and evaluates the proposed and actual disciplinary actions taken by Gulf Coast Veterans Health Care System managers related to the events of the day in question, and takes action as appropriate.
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14957